HESI LPN
Fundamentals of Nursing HESI
1. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?
- A. Avoid standing up too quickly.
- B. Increase fluid intake to stay hydrated.
- C. Eat more salt to help retain fluids.
- D. Wear compression stockings during the day.
Correct answer: A
Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.
2. A client has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and their family?
- A. Check the cord routinely for frays or tearing
- B. Use oxygen around open flames
- C. Store oxygen concentrator in a closet
- D. Wear synthetic clothing to prevent static electricity
Correct answer: A
Rationale: The correct answer is to instruct the client and their family to check the cord routinely for frays or tearing. This is crucial to ensure the safety and proper function of the oxygen concentrator. Choice B is incorrect because oxygen should never be used around open flames due to the risk of fire. Choice C is also incorrect as oxygen cylinders or concentrators should not be stored in a closet due to ventilation and safety concerns. Choice D is incorrect because synthetic clothing can generate static electricity, which could pose a risk around oxygen equipment.
3. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?
- A. ''Incident report completed.''
- B. ''Client climbed over the bedrails.''
- C. ''Client found lying on the floor.''
- D. ''Client was trying to get out of bed.''
Correct answer: C
Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.
4. The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?
- A. I will stop taking the medication if I experience dizziness.
- B. I will monitor my blood pressure regularly.
- C. I will avoid drinking alcohol while taking this medication.
- D. I will rise slowly from a sitting to a standing position.
Correct answer: A
Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.
5. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
- D. Before changing assignments, determine which staff members have fitted particulate filter masks
Correct answer: D
Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.
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